Blood Group Hitch Goes In Kidney Transplants

It was love that prompted Nashik resident Meera Dhikale to donate one of her kidneys to her husband Fakira, but in the process the couple may well have written a fresh chapter in the country’s organ transplant medicine.

The transplant, conducted on September 2, had two noteworthy features: one, it was performed between persons with incompatible blood groups, and two, it was done without the mandatory removal of the recipient’s spleen.

"Earlier when we did such incompatible surgeries, it involved two major operations in the same session: the transplant itself and the splenectomy,’’ says Dr Bhupendra Gandhi, nephrologist with Jaslok Hospital, the only centre in the country to have performed 25 such transplants in the last seven years. "In Fakira’s case, for the first time in this country we used a drug called Rituximab to reduce the antibodies in his blood in place of the splenectomy. Thus we reduced the chances of Meera’s donated kidney being rejected by Fakira’s body.’’

For India, the Dhikales’ method could be a way to increase the organ donor pool. The country’s burden of chronic kidney disease increases by almost one lakh new patients every year,but there is a dearth of donors,including cadaveric donors.Thus, the incompatible blood group donation–called ABO incompatible transplants–could be the way forward even though some doctors say it has higher rejection rates than the matched transplant procedure and is more expensive. CMC Hospital in Vellore is the only other centre in the country to do these transplants.

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Incompatible transplants are not new; Jaslok itself performed the first such transplant seven years ago. In 2006, Vikas R’s wife donated a kidney to him and he is doing well. "We had no one else among our blood relations who could donate a kidney to me. So we decided to go ahead with this new procedure,’’ said Vikas (name changed), who is also Dr Gandhi’s patient.

Commending the work done by Jaslok Hospital and CMC Vellore, Dr Sandeep Guleria, nephrologist with the All India Institute of Medical Sciences in Delhi, said, "ABO Incompatible transplants are a good way of increasing the donor pool, and the procedure is not medically difficult. But it costs much more than a transplant between matched donors and carries a slightly higher risk of rejection.’’

A city–based nephrologist who did not want to be named, said, "If transplants between matched donors carry a 98% chance of success, then ABO incompatible donations would have less than 80% chance of success.’’ A senior transplant surgeon added that the cost factor for ABO incompatible transplants–which is more than Rs 1 lakh extra–makes it an unfavourable option.

As for 45–yearold Meera, who has been discharged from hospital, and 47–yearold Fakira, the transplant means they can be home for their five children. A worker in the government mint in Nashik, Fakira didn’t need much convincing about the new procedure. "It seemed to be my only chance,’’ he says. "And my wife was adamant that she would be my donor.’’

What Is Abo Incompatible Transplant?
Usually, transplants involve donors and recipients with the same blood group. If their blood groups are incompatible, then the anti–bodies in the recipient’s blood will reject the donated kidney
But in the last few years, Japan, Sweden and the US have evolved a method in which the antibodies in the to–be recipient’s blood are removed before the transplant. Chances of rejection are then lowered

How Is It Done?
First, the antibodies in the to–be recipient’s body are removed to prevent the donor’s kidney from being rejected. This can be done using two methods. In one, the patient is given Rituximab–a drug to suppress the antibody production. In the UK, this is given 30 days before the transplant and again at the time of the transplant, along with other anti–rejection drugs. Alternatively, the patient’s spleen is removed after the plasma exchange.

The patient also undergoes plasma exchange: The to–be recipient’s plasma (a part of the blood that contains antibodies) is removed and replaced with new plasma. The procedure takes around three hours. Different processes are followed across the world. In the West, plasma exchange is carried out on alternate days for 10 days before the transplant, while doctors in India do it every day for five days before the transplant. Only after the level of antibodies has fallen to the desired level, is the transplant conducted.

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